Identifying optimal techniques for laparoscopic sleeve gastrectomy based on outcomes of surgeons ranked by safety and efficacy
Varban O, Finks JF, Carlin A, Kemmeter P, and Dimick J. Identifying optimal techniques for laparoscopic sleeve gastrectomy based on outcomes of surgeons ranked by safety and efficacy. Surg Endosc Interv Tech 2018; 32(1):S11.
Surg Endosc Interv Tech
Background: Considerable technical variation exists when performing laparoscopic sleeve gas-trectomy (SG). However, little is known about which techniques are associated with optimal outcomes. Objective: To identify technique-specific variables common among surgeons with the best out-comes for SG based on rankings for safety and efficacy. Methods: Practicing surgeons (n = 30) voluntarily submitted a video of a typical SG between 2015-2016. Technique-specific data was captured from each video as well as a survey questionnaire and included: bougie size, stapler vendor, type of staple loads, oversewing, imbricating, use of buttressing, use of fibrin sealant, intraoperative leak test, intraoperative endoscopy and drain placement. Surgeon-specific operative times, risk-adjusted 30-day complication rates as well as 1-year patient reported outcomes were obtained from cases performed by surgeons during the study period (n = 7,023) using a state-wide bariatric-specific data registry. Surgeons were ranked using a composite score based on 4 outcome variables for safety (overall and severe complications, hemorrhage and reoperation rates) and 2 outcome variables for efficacy (weight loss and satisfaction rate). Pearson's r coefficient was calculated to identify a correlation between surgeon rankings for safety vs. efficacy. Univariate analysis was performed to identify technique-specific variables associated with surgeons in the top and bottom quartiles for safety and efficacy. Results: Surgeons ranked in the top quartile for safety (n = 7) had an overall complication rate of 2.87% (0%-4.9%), severe complication rate of 0.46% (0%-1%), hemorrhage rate of 0.29% (0%-1.1%) and reoperation rate of 0.11% (0%-0.6%). Surgeons ranked in the top quartile for efficacy (n = 8) had patients with a mean excess body weight loss of 61.3% (58%-63.6%) and a satisfaction rate of 89.6% (87.5%-93.3%) at 1 year after surgery. There was no correlation between surgeon's rankings for safety and efficacy (r = 0.12, p = 0.52). Surgeons ranked in the top quartile for safety and efficacy had shorter operative times than surgeons in the bottom quartiles (64 min vs 89 min, p\0.0001 and 75 min vs 95 min, p\0.0001, respectively). Surgeons ranked in the top quartile for safety were more likely to use buttressing material (71.4% vs 16.7%, p = 0.05). The remaining technique-specific variables were not significantly different between top and bottom quartiles. Conclusions: Surgeon rankings for safety did not correlate with those for efficacy. The safest surgeons were more likely to use buttressing material, otherwise, there were no unique technique-specific variables among top performers. Top ranked surgeons had faster operative times, indicating that there may be other metrics of technical quality that correlate to optimal outcomes.